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NOTE: This sample template is used to assist nursing homes in complying with COMAR 10.07.02.24 (Emergency Preparedness). It is not meant to exclude other formats so long as they include all elements of the regulations.

Instructions for using the Comprehensive Care Facilities & Extended Care Facilities Self-Report Form

The form was created for use by facilities to self-report alleged violations of neglect and abuse, including injuries of unknown source, and misappropriation of resident property/funds (refer to April 12, 2005 memorandum from Carol Benner regarding the clarification of reporting requirements). It is not mandatory that facilities use this form, but a facility must include, at a minimum, the information requested on this form.

The form should be used to forward both the “first report” and “results of investigation” to the OHCQ/Long Term Care Unit via fax 410-402-8113 or e-mail nh.selfreport@maryland.gov.

The facility should complete the top of the form for the “first report” and forward to OHCQ within 24 hours of the incident.

The results of the investigation of the reported incident, should then be entered on the bottom of the form and be forwarded to OHCQ. One complete form (i.e., includes the first report and investigation results) should be forwarded within 5 days of the incident.

The Nursing Home Self-Report Form can be downloaded and viewed with Microsoft® or Word Adobe Acrobat®.

SAMPLE STAFFINGA sample of how a facility could use an erasable white board with names hand written in to be in compliance with .55 A and B about staffing. Remember this is to be done per shift per unit or floor